COMMON INTRAOPERATIVE ANESTHESIA PROBLEMS by dffhrtcv3

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									          Pediatric Pain :
Neuroaxial Blockade for Acute Pain Management

         Intrathecal Administration

           Epidural Administration
                     single
                   continuous
              post-op management
 “The Advantages to be gained
by the use of spinal anesthesia
have so far impressed me that I
am convinced it will occupy an
 important place in the surgery
   of children in the future.”

                   H. Tyrell-Grey
                   The Lancet 1909
          Introduction
The following sessions illustrate     the
advantages for using neuro-axial blockade
for pediatric pain management either
acutely or in combination with a general
anesthetic. The approaches delineated
remain    designed   for   the    general
practitioner as well as specialist. Even
though perhaps still evolving, these
techniques have and continue to benefit
many.
                 CASE
 A three month of age boy is to have a
 right inguinal hernia repaired. Upon review
 he has had respiratory distress syndrome.

Wght: 3 kg
Hct: 30%
             Preoperative Evaluation
                Emergency? No
     Why is the Surgery being performed?

              PREOPERATIVE EVALUATION:
  Problems                 History & Physical            Laboratory Tests
1. RDS                 litany of basic knowledge   CBC
2. Hyaline Membrane Ds                             Electrolytes
2. Prematurity                                     Coags
3. Airway                                          CXR (ABG, FEV1/FVC, F-V loop)
5. Full Stomach




  ANY ISSUES TO BE ADDRESSED PRIOR TO ENTERING THE O.R.
Choice of Anesthesia
    General Anesthesia
   Regional Anesthesia
  Peripheral Nerve Block
        IV Regional
           MAC
           Local
          Techniques for General
                Anesthesia
4 Concerns to Guide the Plan:
Airway/ Full Stomach/ Volume Status/ Medical Problems

                        Is Regional an Option?
                           Rapid Sequence
                       Modified Rapid Sequence

     Concerns                    How                     Medications
 1. Airway                1. IV-IM               1. Administration sequence
 2. Full Stomach          2. Inhalational        2. Including NMB Agent
 3. Volume Status         3. Awake Fiber Optic   3. Analgesic Component
 4. Medical Problems      4. Local Trach
Intrathecal Administration
        I keep six honest serving men
         (They taught me all I knew);
  Their names are What and Why and When
             And How and Who.
             Rudyard Kipling 1865-1936
  --The Just-So Stories (1902). The Elephant’s Child
  What     Efficient: What Needed
  Why      Physiology, Safety & Efficacy
  When     Patient Centered, Timely, Equitable
  How      Treatment
  Who      Background Demographics Introduction
  Where    Anatomy
        What?
Anatomy : Intrathecal Space
Why?


   The spinal cord anatomy
   of the infant differs
   from the adult, since
   the cord terminates at
   L3 in the infant not L2
   as in the adult.
                    When?

 For high risk infants less than 1 year of age. These
include infants with certain congenital anomalies, a history
of prematurity, or a history of neonatal respiratory
distress syndrome thereby increasing the risk for general
anesthesia.
                                              How?
Technique: 1. Suggest premedication with atropine only
           2. ASA monitors placed while infant remains fully awake in the OR
           3. While receiving supplemental 02 with chin extended, the infant is placed into position
           4. Prepare the lumber area with iodine solution
           5. Identify the lowest palpable interspace below L3
           6. Use 1% procaine for the skin weal analgesic
           7. Draw 0.2 cc of 1% tetracaine in a TB syringe and add 0.2 cc of 10% dextrose for a
               hyperbaric solution. By adding 0.02 cc of epi 1:1000 the effect may increase upwards to 100
               minutes
           8. Have available a variety of 22 or 25 gauge pediatric Quincke or Whitacre type spinal needles
           9. After obtaining free flow of CSF from all planes of needle rotation, do not aspirate
          10. Inject the hyperbaric solution plus 0.4cc more than needed to compensate for dead space.
          11. Leave the needle in place for about 5 seconds to prevent back tracking of the solution from
              the CSF, thus avoiding an incomplete or failed block.
          12. Place the infant supine, while observing for the onset of lower extremity flaccidity, usually
              within 2 minutes.
          13. Maintain strict supine positioning until the block establishing the block, without leg elevation.
              Such prevents potential migration of the block and a total spinal
Infant Spinal Anesthesia

            1……………………….add Tb syringe

            2…………………...add spinal needle

            3……………………...add medication
Infant Spinal Anesthesia




            4...use local
Infant Spinal Anesthesia


            5………...…………..attach syringe firmly

            6………………………………...do not aspirate

            7….it is ok to inject into bloody CSF
Infant Spinal Anesthesia

            8…...load syringe sterile and
                 have surgeon inject it



            9…….if spinal begins to wear
                 off, repeat the dose
Infant Spinal Anesthesia




     10…...start IV in anesthetized ankle
Infant Spinal Anesthesia




     11…..note the placement of the drapes
Infant Spinal Anesthesia




                  close up
Infant Spinal Anesthesia




close up
                              Who?
High risk infants who had been born prematurely or were treated for
   neonatal respiratory distress

Infants with congenital anomalies such as laryngomalacia, macroglossia,
   or microagnathia

Most commonly the surgical indication is bilateral inguinal hernia repair,
  but other surgery below the umbilicus is also considered:
                     colostomy for imperforated anus
                     recctal biopsy
                     closed reduction of hip dislocation
                     circumcision
                     correction of club foot
                     etc.
High Risk Infants Who Had Been
        Born Prematurely
Consider Surgery Below the Umbilicus
         Where?


Lowest palpable interspace below L3
Anatomy
                   Pitfalls
Dose:       1 mg for those infants < 1 year of age
            then 0.25 mg/kg
            mean duration of 84 minutes
            with epi mean increased to 109 minutes

Alternates: 0.5% bupivicaine or 2.5% lidocaine
                                  Results
group infants   proceedures attempt attempt   unsuccessful spinals requiring supplementation
           #       #           1st     2nd           #                         #
high risk 36       36          31       5            0                         6
anomaly 8          11          10       1            0                         3
term      34       34          22       4            8                         5
totals    78       81          63       10           8                         14
                       Safety
 Most Difficulty Lies in Positioning an Awake Wiggling Infant

 The CSF Flow Must Remain Continuos As the Needle Rotates

  Bloody Taps Occur More Often If Not Midline in Approach

With a Bloody Tap More Difficulty Arises in Locating the CSF

BP and Bradycardia Less Likely With Infants Than With Adults
   The CSF Flow Must Remain
Continuous as the Needle Rotates
                  References
Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW,
  Mazuzan JE. Spinal Anesthesia for Surgery in Children and
  Infant. Anesth Anal 1984; 63:359-62.

Gregory, GA and Steward, DJ. Life Threatening Perioperative
  Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983.

Steward, DJ. Preterm Infants are More Prone to Complications
  Following Minor Surgery than are Term Infants.
  Anesthesiology 56:304-306, 1982.
  PEDIATRIC PAIN
Epidural Administration

      Kiddy Caudals
Epidural Administration
       I keep six honest serving men
        (They taught me all I knew);
 Their names are What and Why and When
            And How and Who.
            Rudyard Kipling 1865-1936
 --The Just-So Stories (1902). The Elephant’s Child
What      Efficient: What Needed
Why       Physiology, Safety & Efficacy
When      Patient Centered, Timely, Equitable
How       Treatment
Who       Background Demographics Introduction
Where     Anatomy
Single Administration
            What?
        1
                With very little equipment
                which includes a skin prep,
                needle of choice, and
            3   desired local anesthetic:
                    1………………...………...alcohol pad
5   4               2…….povidone idoine solution
        2
                    3……….formal prep and drape
                    4……………..appropriate needle
                    5…..desired local anesthetic
                single shot caudals provide
                excellent analgesia
Why?


       Caudals      provide     effective
       adjunctive operative analgesia
       lasting upwards of 4 to 6 hours
       post-surgically    in     pediatric
       patients.     Moreover,      these
       techniques are relatively safe and
       easy to perform.
                           When?
after induction of general anesthesia but before the
               onset of surgical incision.
  -the time required for placement translates into time regained post
          operatively secondary to earlier anesthetic emergence


      -patients commonly remain pain free for several hours post.

 -greatly reduces the risk of laryngospasm due to surgical stimulation
  especially during perineal procedures obviating the need for intubation
                 and the possibility of post-operative croup
                      How?
1. Properly position the patient
2. After the skin preparation, use the hypodermic
   needle of choice at a 60 degree angle to the skin
   until the sacrococygeal membrane is peirced.
3. Note a distintive ‘pop’ upon entering the sacral canal
4. Then further advance the hypodermic another 2mm
   parallel the plane of the spinal axis.
5. Gently aspirate to confirm neither an intravascular
   nor an intrathecal injection of local anesthetic.
6. Introduce the agent into the caudal epidural space
How to Position?
            How to Proceed?
1. After the skin preparation,
   use the hypodermic needle
   of choice at a 60 degree
   angle to the skin with the
   bevel    down until the
   sacrococygeal membrane is
   peirced.
2. Note a distintive ‘pop’ upon
   entering the sacral canal
3. Then further advance the
   hypodermic another 2mm
   parallel the plane of the
   spinal axis.
Caudal Epidural


     1……….. enter membrane at 30 to 40 degrees

     2…………………………..flatten toward the rectum

     3…………………….advance about 1/4 to 1/2 inch

     4……slip catheter off the needle into space
Caudal Epidural



        5…………………….do not inject air

        6…………………..aspirate catheter
Caudal Epidural



        18 gauge cathalon

        arrow caudal/epidural kit
Caudal Epidural



      suitable dressing

      tape up the side to allow for bovie pad
                     Who?
children having surgical procedures below the umbilicus:

                     circumcisions
                      orchidopexy
                 inguinal hernia repair
                    hydrocelectomy
                     rectal dilation
        lower extremity orthopedic procedures
      Where

Through the caudal space
    Pediatric Acute Pain
Management Post-Operatively:


   Continuous Epidural Infusions
  Cardiothoracic Surgery

At our institution epidural remains the standard of care. So
much so that parents must specifically state refusal for this
preferred method of intra-operative and postoperative
analgesia not to be provided.

                                         David A. Rosen, MD
             Epidural

Dr. Chris Abajian pioneered spinal anesthesia for infants at
the University of Vermont and maintains the largest
database in the world on outcomes associated with this
technique
                                         Chris Abajian, MD
Epidural

           18 guage cathalon




           arrow caudal/epidural kit
Caudal

         22      gauge jelco catheter
              inserted   through    the
              sacrococygeal    ligament
              with a 24-gauge styleted
              catheter threaded 1-3 cm
              into the caudal space
              usually.

         arrow caudal/epidural kit
Epidural

     suitable dressing




     tape up the side to allow for bovie pad
Caudal

    suitable bio-occlusive dressing applied
       with a drape below and above the
       insertion site providing a sterile
       barrier resisting contamination from
       urine and feces. Tape the catheter
       connector to a tongue blade to add
       1-2, 4-way stopcocks for medication
       infusions

    tape up the side to allow for bovie pad
Caudal Medications
          Morphine

       Hydromorphone

          Clonidine

      Local Anesthetics
          lidocaine
         bupivacaine
         ropivacaine
         Caudal Medications
                                  Morphine

    BOLUS           INFUSION               RATE                SIDE EFFECTS
  0.04 mg/kg        0.075 mg/kg        0.125 mcg/kg/min
                                                                   somulence
>14 kg 10cc PFNS >14 kg 10cc PFNS          1 cc/hr                   nausea
<14 kg 5cc PFNS   <14 kg 5cc PFNS          0.5 cc/hr                vomiting
                                                                    pruritis
< 1kg 3cc PFNS    < 1kg 3cc PFNS       0.025 mcg/kg/min




               *epidurally administered opiods require a minimum
                    of 8 hours of continuous pulse oximetry
          Caudal Caveats
                             Morphine
If only using morphine throughout the case after the bolus of 0.04
mcg/kg infuse at 0.125 mcg/kg/min, then stop near the end to
facilitate extubation. Restart the infusion upon the child’s
awakening if placed in the caudal region as noted already. Or if the
catheter lies in the thoracic segments, for Down’s children or
premature infants begin at half the rate 0.0625 mcg/kg/min.
Should side effects (somulence without discomfort) arise
decrease the infusion by 0.025 increments.

 For those individuals requiring continued ventilatory support
simply maintain the above maximum infusion.

Typically the epidural infuse for 2-3 days post-op thought upto
even 5 days are not uncommon
           Caudal Medications
                        Hydromorphone

BOLUS       INFUSION        POST OP ADJUSTMENTS          SIDE EFFECTS

0.5-1.0*     0.1-3.5*        0.1 and 0.5 increments*   akin to morphine,
                                                       and more lipophilic
                                                       thus the catheter
                                                       tip lies in proximity
                                                       to     the    desired
                                                       dermatomal area.

                             *mcg/kg/hr

              2xwghtx24 = mg added in PFNS for total of 48cc
           Caudal Medications
                              Clonidine

BOLUS       INFUSION         POST OP ADJUSTMENTS            SIDE EFFECTS

0.5-1.0*     0.1-5*            0.1 and 0.5 increments*     profound analgesia
                                                                sedation
                                                             hypotension**
                                                             bradycardia**




                                *mcg/kg/hr
                      **ideal for coarctation patients
                   PF Clonidine comes as 100 or 500 mcg/cc
            reduce the concentration by tenfold to 10 or 50 mcg/cc
           Caudal Medications
                      Local Anesthetics: Bolus

  LOCAL                 TEST DOSE                   LOADING DOSE
lidocaine (L)     0.1cc/kg 1-1.5%L epi 1:200k   1-1.5% L bolus to desired level
bupivacaine (B)   0.1cc/kg 0.25%B epi 1:200k    0.25% B 0.056 cc/kg/seg
ropivacaine (R)
           Caudal Medications
                            Local Anesthetics: Maintanence

  LOCAL                      INFUSION                        SIDE EFFECTS
lidocaine (L)         0.75% L @10-20mcg/kg/hr*                somulence
bupivacaine (B)      0.1-0.125%** B @0.25mg/kg/hr            hand tingling
                                                     extra-dermatomal numbness
ropivacaine (R)       0.1% R @ 10-20mcg/kg/hr     pain with adequate sympathectomy




    *lidocaine level obtained 12hr post op then daily while the infusion continues
                  **0.125% B used for children reaching tanner stage 4
                 Side Effects

        Nalbuphene 0.025 mg/kg q 2hr prn nausea, vomiting, pruritis
           should vomiting persist decrease the narcotic infusion

                     failing two trials of nubain, ondensatron
                    0.15 mg/kg up to 4mg iv q 4hr prn nausea,
                                 vomiting, pruritis
              prophylactic low dose propofol infusion starting at
              1 titrating upto 10 mcg/kg/min might be considered

               if these measures prove ineffective consider
           metaclopramide 0.1mg/kg or dexamethasone 0.5mg/kg
               vomiting more commonly in children > 3 years
               facial itching noted more often in non-infants
respiratory depression rarely occurs with adherence to the dosage schedule
              Complications
   16 years of experience & over 5000 cases:
Problems                               Incidence
Insertional bleeding                          5%
Catheter bleeding                             <1%
Intrathecal migration                       .05%
Catheter Shearing         once only (no sequalae)
Durocutaneous fistula                           0
Cauda-equina syndrome                  once only*
Meningitis                               twice**

       * resolved spontaneously after 1 week
 **developed weeks later following catheter removal
        and no evidence relating to the epidural
      Caveats
select those with optimal anatomy,
remain    reluctant   for    those
without a base despite a caudal
dimple in such circumstances
consider a low lumbar approach
instead.



remember the ‘circle of errors’



place the non-dominant hand
across the sacral region dorsally
palpating for an inadvertent
subcutaneous injection by noting a
“bulge” midline.
           Epidural




X-ray showing wrong catheter placement
           Epidural




X-ray showing correct catheter placement
                   References
Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW,
  Mazuzan JE. Spinal Anesthesia for Surgery in Children and
  Infant. Anesth Anal 1984; 63:359-62.

Broadman, Lynn M. Regional Anesthesia in Children. West
  Virginia University, 1994.

Gregory, GA and Steward, DJ. Life Threatening Perioperative
  Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983.

Rosen, A. David. Continuous Caudal Morphine Postoperatively.
  January 26th, 2004.

Steward, DJ. Preterm Infants are More Prone to Complications
  Following Minor Surgery than are Term Infants.
  Anesthesiology 56:304-306, 1982.
                              Questions
T or F   1. In the infant the spinal cord terminates at L2 as in the adult.

T or F   2. Infants with a history of prematurity are excellent candidates
           for pediatric spinals especially for surgery above the umbilicus.

T or F   3. As with most local anesthetic administration one should aspirate
            prior to injection for the infant spinal.

T or F   3. Should bloody CSF appear one should immediately abandon the
            pediatric spinal.

T or F   4. BP and bradycardia are less likely with infants than with adults.
                              Questions
T or F   1. In the infant the spinal cord terminates at L2 as in the adult.

T or F   2. Infants with a history of prematurity are excellent candidates
           for pediatric spinals especially for surgery above the umbilicus.

T or F   3. As with most local anesthetic administration one should aspirate
            prior to injection for the infant spinal.

T or F   3. Should bloody CSF appear one should immediately abandon the
            pediatric spinal.

T or F   4. BP and bradycardia are less likely with infants than with adults.
                              Questions
T or F   5. Single administration caudals provide excellent analgesia.

T or F   6. “Kiddie Caudals” reduce the risk of laryngospasm due to surgical
            stimulation.

T or F   7. The bevel of the hypodermic needle used for injection should be
            pointing upwards as with placement of a peripheral intravenous.

T or F   8. As with most local anesthetics one should aspirate the epidurally
            placed catheter prior to injection.
                              Questions
T or F   5. Single administration caudals provide excellent analgesia.

T or F   6. “Kiddie Caudals” reduce the risk of laryngospasm due to surgical
            stimulation.

T or F   7. The bevel of the hypodermic needle used for injection should be
            pointing upwards as with placement of a peripheral intravenous.

T or F   8. As with most local anesthetics one should aspirate the epidurally
            placed catheter prior to injection.
                              Questions
T or F   9. Post-op pain relief requires an institutional commitment.

T or F   10. Any dressing will suffice for protection of the epidural catheter
           insertion site from urine and fecal contamination.

T or F   11. Epidurally administered opiods require a minimum of 8 hours of
            continuous pulse oximetry.

T or F   12. In general once the infusion rates are set for post-op epidurally
           administered analgesics no further adjustments are required.

T or F   13. Careful titration to side effects and adequacy of post-op
           analgesia is required for optimum results using epidurally given
           medication.
                              Questions
T or F   9. Post-op pain relief requires an institutional commitment.

T or F   10. Any dressing will suffice for protection of the epidural catheter
           insertion site from urine and fecal contamination.

T or F   11. Epidurally administered opiods require a minimum of 8 hours of
            continuous pulse oximetry.

T or F   12. In general once the infusion rates are set for post-op epidurally
           administered analgesics no further adjustments are required.

T or F   13. Careful titration to side effects and adequacy of post-op
           analgesia is required for optimum results using epidurally given
           medication.

								
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